Red Book - Adrenal Insufficiency

Question 1

Classify the causes of adrenal insufficiency

Answer 1

Primar, Secondary, Tertiary

Primary - Failure of adrenal - low cortisol
Secondary - Failure of pituitary - low ACTH
Tertiary - Either - failure of hypothalamus (low CRH)
OR - chornic steroid use

Question 2

Causes of primary adrenal insuffiency

Answer 2

Auto-immune - Addisons

Infection - TB (adrenal infiltrate), funal infection (histoplasmosis)
HIV causing CMV infection and adrenalitits

Cancer - Mets or primary

Drugs - etomidate, ketoconazole

Other - Critical illness insufficiency (relative)
Adrenalectomy
Irradiation
Iron deposit - haemochromatosis

Question 3

Causes of secondary/tertiary

Answer 3

Chronic steroid use suppresing the axis

Malignancy brain
Haemorrhage
Infarct (sheehans)

Question 4

How to diagnose adrenal insufficiency

Answer 4

Cortisol and ACTH

Primary - low cortisol high ACTH
Secondary - both low

Beware exogenous steroids

Standard test - Synacthen test
Cortisol measured beofre and after ACTH
Failure to rise after 30 minutes - adrenal insufficency

Negative - rules out primary BUT NOT secondary

Adrenal antibodies and radiology

Question 5

What is addisons

Answer 5

Adrenal cortex fails due to autoimmune disease.

Reduced or absent cortisol levels

Causes - autoimmune, irradiation, surgery

Often with mineralocorticoid deficiency

Question 6

Why pigmentation in addisons

Answer 6

No coritsol means high ACTH

ACTH has a precurso molecule (pro-opiomelanocortin) which makes melanocyte stimulating hormone

Increases –> pigments

Question 7

Describe the Addisonian crisis

Answer 7

Systems:
CVS: High output distributive shock (low BP, tachy, vasoplegua

Neuro: Lethargy, fatigue, weakness, headache, dizzy, confusion, LOC

GI - D&V, abdo pain

Skin - pigmentation

Ix -
Low Na, High K, metabolic acidosis
Low sugars

Question 8

Biochemical abnormalities in addison crisis

What other diseases may present with is

Answer 8

Ix -
Low Na, High K, metabolic acidosis
Low sugars

Pernicious anaemia
Graves (autoimmune)

Question 9

Management

Answer 9

ABCDE
High output shock that needs vasopressors

Differential is sepsis

Focus - correct BP, electrolyte issues and replace cortisol

Resus
Large bore iv access
FBC, U&E, Glucose, Cortisol, ACTH
Fluid resus
BM and correct

Replace steroids
200mg iv hydrocrot followed by 100mg 6 hourly
Mineralocorticoids not needed acutely
Consider fludrocortison with endocrine

Invasive monitoring and level2-3 care

Find that cause!
Sepsis/Surgery
Steroid use
Autoimmune disease
Infectious disease
Drugs
Cancer
Pregancy

Question 10

What is relaitve hypoadrenalism

Answer 10

Common in critical illness

Describes the relative and absoltue failure of cortisol

Surviving sepsis - you can give steroids in vasopressor resistant shock (low evidence)

But do not stratify by measurements of cortisol